medbrainfandomcom-20200214-history
Central Line Insertion
Indications Generally therapeutic, for the infusion of the following : # Vasopressors / Inotropes # Concentrated electrolytes # Chemotherapy # Total parenteral nutrition Also facilitates # Frequent blood sampling # Monitoring Central Venous Pressure (only Jugular) # Central Venous Oxygen Saturation Monitoring # Pulmonary Artery Catheter Insertion # Transvenous Pacing # Hemodialysis Caveats # Does not necessarily allow you to infuse large volumes - large peripheral veins are the best # Increased risk of infection # Insertion process may delay treatment Contraindications Absolute # Refusal by a competent patient # Superior Vena Caval Obstruction # Local infections or trauma # SVC thrombosis Relative # Coagulopathy # Limited neck mobility # Distorted or suboptimal anatomy - previous surgery, radiotherapy, known thrombosis # Uncooperative patient Complications Equipment # Working ultrasound device with vascular probe # Sterile sleeve - commercial kit (sleeve, rubber bands, gel) or Green towel, tegaderms, lignocaine gel / sterile US gel # Sterile PPE - Cap, gown, sterile gloves (Size 7), sterile napkins # Sterile drape for patient (commercial kit or green drape with hole) # Local anesthesia set - lignocaine x 2 vials. Insulin syringe or 5ml syringe with blue needle # CVC Line kit # I&D set - artery, forceps, scissors, gauze, tray # Saline - either normal or heparinised for saline (check for coagulopathy / platelets prior) # Blood tubes - for cultures / biochemistry etc # Antiseptic - chlorhexidine or iodine # Blade - for stab incision # Silk suture - to suture the line to skin # Transducer set # Dressing to keep the CVC Clean post-insertion Patient Preparation # Consent - in best interests of patients in an emergency. Explain to family later # Explain procedure and reassure patient # Analgesia / sedation - especially for agitated, delirious patients # Monitoring - cycle BP, continuous SpO2 # KIV O2 supplementation # Position - supine for femoral, Trendelenburg for IJ Insertion Technique # Scout Scan to confirm site, anatomy, compressibility # Open all the kits and prepare and check the equipment # Surgical hand wash # Gown and glove up # Prepare the local anesthetic # Prime the line with saline # Clean and drape the patient (IJV - trachea, EAC, clavicle, Femoral - umbilicus, mid thigh) # Cover the US probe with a sleeve # Recheck anatomy in case patient has moved # Apply local anesthetic to the region # Fill the syringe with 1-2mls of saline # Uncap the guidewire # Bring the essential equipment onto the drape for easy access (CVC, Introducer, Dilator, Guidewire, blade) # Push the needle in at 45 degrees aspirating as you advance # Once obtaining flashback, advance forward slightly and aspirate further, if difficulty advancing, withdraw wire, check needle position # Stabilise the needle, remove the syringe # Push in the guidewire Till about 2-3 inches remain # Tamponade the site while withdrawing the needle, ensuring the guidewire is in place # Make a stab incision # Insert the dilator till about halfway through and twist to ensure that the tissue is dilated # Remove the dilator while ensuring that the guidewire does not move # Open the clip to the brown port and remove the stopped # Slide the CVC through the wire till either flush or 1-2 cm margin (for IJ lines), do not let the guidewire go # Aspirate and flush to ensure smooth flow - may consider collecting blood at this point # Place cuff (optional for femoral) # Suture the line to secure Post-insertion care # Apply appropriate dressing # Arrange for a check XR if IJ line (looking for correct position / pneumothorax) # Review need for line daily, remove when not needed # When handling line, hand wash # Alcohol swab line thoroughly before administering medications / drawing blood samples